ATTACHMENT_5_SELF_SCORING_TECHNICAL_CAPABILITY_WORKSHEET_Amended_10Feb2017.xlsx

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Defense Health Agency Medical Q-Coded Services (MQS) Acquisition
Solicitation number
HT0050-16-R-0001
Issued by

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ATTACHMENT 5 SELF SCORING TECHNICAL CAPABILITY WORKSHEET Amended 10Feb2017.

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HT0050-16-R-0001_0004.pdf PDF
HT0050-16-R-0001_0003.pdf PDF
HT0050-16-R-0001_0002.pdf PDF
Q&As_Amendment_0002_v_2.pdf PDF
Attachment_2_Price_Evaluation_Sample_Market_Segment_TOPR_0002.pdf PDF
ATTACHMENT_2_PRICE_EVALUATION_Sample_Market_Segment_TOPRs_Amended_10Feb2017.pdf PDF
QAs_Amendment_1_10Feb17.pdf PDF
HT0050-16-R-0001_Amendment_1_10Feb2017.pdf PDF
ATTACHMENT_4_CONTRACTOR_TEAM_ORGANIZATION.docx DOCX document
ATTACHMENT_6_PAST_PERFORMANCE_QUESTIONNAIRE.docx DOCX document
ATTACHMENT_3_TECHNICAL_CAPABILITY_VALIDATION_SHEET.docx DOCX document
ATTACHMENT_9_PAST_PERFORMANCE_INFORMATION_TOOL.pdf PDF
ATTACHMENT_2_PRICE_EVALUATION_Sample_Market_Segment_TOPRs.pdf PDF
ATTACHMENT_4_CONTRACTOR_TEAM_ORGANIZATION.pdf PDF
ATTACHMENT_2D_Dental_Pricing_Worksheet_v2.xlsx XLSX spreadsheet
ATTACHMENT_8_CLIENT_AUTHORIZATION_LETTER.pdf PDF
ATTACHMENT_5_SELF_SCORING_TECHNICAL_CAPABILITY_WORKSHEET.xlsx XLSX spreadsheet
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ATTACHMENT_7_SUBCONTRACTOR-TEAMING_PARTNER_CONSENT_LETTER.pdf PDF
ATTACHMENT_2A_Physician_Pricing_Worksheet_v2.xlsx XLSX spreadsheet
ATTACHMENT_2B_Ancillary_Pricing_Worksheet_v2.xlsx XLSX spreadsheet
HT0050-16-R-0001.pdf PDF
ATTACHMENT_3_TECHNICAL_CAPABILITY_VALIDATION_SHEET.pdf PDF
ATTACHMENT_6_PAST_PERFORMANCE_QUESTIONNAIRE.pdf PDF
ATTACHMENT_2C_Nursing_Pricing_Worksheet_v2.xlsx XLSX spreadsheet
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Self-Scoring Sheet

MQS Acquisition
Solicitation:
Attachment 5
SELF SCORING TECHNICAL CAPABILITY WORKSHEET
(See instructions in 52.212-1, Attachment 5, Self Scoring Technical Capability Worksheet)

OFFEROR NAME:

Enter an X in the appropriate segment(s) proposedOfferor must select at least one market segment to compete for an award on this solicitation (see 52.212-1, Attachment 5, Self Scoring Technical Capability Worksheet)
Market SegmentPhysicianNursingAncillaryDental
0000
Offeror is proposing in the following market segments: (Selected segment(s) must match capability in Attachment 4, Team Organization)
VOLUME II - TECHNICAL CAPABILITY
RFP SectionItemSelf Scoring SectionPoint ValueSupporting Documentation
SCOPE (Type of clinical services provided)
PHYSICIAN MARKET SEGMENT (Relevant experience must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceRelevant Experience - Common Positions (One supporting document must be from the Prime contractor)Enter an X in the appropriate column with the number of FTEs placedCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 2> 2, but < 6> 6ValueFile Name (e.g., MY COMPANY.VOLII.PHYSICIANS.COMMMON.TAB2A.pdf) See Table 1, Proposal Organization
Point Value:20406080
Total PointsFALSEFALSEFALSEFALSE
5.1; 5.2; 5.3Contract placing Anesthesiologists0
FALSEFALSEFALSEFALSE
Contract placing Family Practice Physicians0
FALSEFALSEFALSEFALSE
Contract placing General Surgeons0
FALSEFALSEFALSEFALSE
Contract placing Internists0
FALSEFALSEFALSEFALSE0
Contract placing Neurologists0
FALSEFALSEFALSEFALSE0
Contract placing Pediatricians0
Other Physician Labor Category identified in Exhibit 3: Point Value:10203040Value
FALSEFALSEFALSEFALSE0
[Type in one Physician labor category here]0
ReferenceRelevant Experience - Difficult-to-Fill PositionsEnter an X in the appropriate column associated with contract experienceCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 2> 2, but < 4> 4ValueFile Name (e.g., MY COMPANY.VOLII.PHYSICIANS.HARD.TAB2A.pdf) See Table 1, Proposal Organization
Point Value:20406080
FALSEFALSEFALSEFALSE
5.3.3Contract placing Emergency Medicine Physicians0
FALSEFALSEFALSEFALSE
Contract placing Psychiatrists0
FALSEFALSEFALSEFALSE
Contract placing Radiologists0
ReferenceRelevant Experience - Physician Clinical Setting (see note below)Enter an X in the appropriate column associated with clinical settingsCPARS/Signed Document (Attachment 3)
YesNoValueFile Name (e.g., MY COMPANY.VOLII.PHYSICIANS.SETTING.TAB2A.pdf) See Table 1, Proposal Organization
FALSEFALSE
1.1Outpatient Clinic (10 point value)0
FALSEFALSE
Community Hospital (10 point value)0
FALSEFALSE
Teaching Hospital (10 point value)0
FALSEFALSE
Other Setting (10 point value)0
PHYSICIAN MARKET SEGMENT TOTAL0
NURSING MARKET SEGMENT (Relevant experience must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceOfferor Relevant Experience - Common Positions (One supporting document must be from the Prime contractor)Enter an X in the appropriate column with the number of FTEs placedCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 3> 3, but < 11> 11ValueFile Name (e.g., MY COMPANY.VOLII.NURSES.COMMON.TAB2B.pdf) See Table 1, Proposal Organization
Point Value:15304560
Total PointsFALSEFALSEFALSEFALSE
5.1; 5.2; 5.3Contract placing Emergency Medicine Registered Nurses0
FALSEFALSEFALSEFALSE
Contract placing Intensive Care Registered Nurses0
FALSEFALSEFALSEFALSE
Contract placing LVNs/LPNs0
FALSEFALSEFALSEFALSE
Contract placing Medical/Surgical Registered Nurses0
FALSEFALSEFALSEFALSE
Contract placing Registered Nurse Case Managers0
FALSEFALSEFALSEFALSE
Contract placing Operating Room Registered Nurses0
FALSEFALSEFALSEFALSE
Contract placing Family Practice Registered Nurses0
Other Nursing Labor Category identified in Exhibit 3: Point Value:5101520Value
FALSEFALSEFALSEFALSE
[Type in one Nursing labor category here]0
ReferenceRelevant Experience - Difficult-to-Fill PositionsEnter an X in the appropriate column associated with contract experienceCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 3> 3, but < 11> 11ValueFile Name (e.g., MY COMPANY.VOLII.NURSES.HARD.TAB2B.pdf) See Table 1, Proposal Organization
Point Value:20406080
FALSEFALSEFALSEFALSE
5.3.3Contract placing Certified Nurse Anesthetists0
FALSEFALSEFALSEFALSE
Contract placing Family Practice Nurse Practitioners0
FALSEFALSEFALSEFALSE
Contract placing Labor and Delivery Registered Nurses0
FALSEFALSEFALSEFALSE
Contract placing Neonatal Intensive Care Registered Nurses0
ReferenceRelevant Experience - Nursing Clinical Setting (see note below)Enter an X in the appropriate column associated with clinical settingsCPARS/Signed Document (Attachment 3)
YesNoValueFile Name (e.g., MY COMPANY.VOLII.NURSES.SETTING.TAB2B.pdf) See Table 1, Proposal Organization
FALSEFALSE
1.1Outpatient Clinic (10 point value)0
FALSEFALSE
Community Hospital (10 point value)0
FALSEFALSE
Teaching Hospital (10 point value)0
FALSEFALSE
Other Setting (10 point value)0
NURSING MARKET SEGMENT TOTAL0
ANCILLARY SERVICES MARKET SEGMENT (Relevant experience must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceRelevant Experience - Common Positions (One supporting document must be from the Prime contractor)Enter an X in the appropriate column with the number of FTEs placedCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 2> 2, but < 11> 11ValueFile Name (e.g., MY COMPANY.VOLII.ANCILLARY.COMMON.TAB2C.pdf) See Table 1, Proposal Organization
Point Value:14284256
Total PointsFALSEFALSEFALSEFALSE
5.1; 5.2; 5.3Contract placing Clinical Pharmacists0
FALSEFALSEFALSEFALSE
Contract placing Clinical Social Workers0
FALSEFALSEFALSEFALSE
Contract placing Medical Assistants (certified and non-certified)0
FALSEFALSEFALSEFALSE
Contract placing Medical Laboratory Technicians0
FALSEFALSEFALSEFALSE
Contract placing Pharmacists0
FALSEFALSEFALSEFALSE
Contract placing Pharmacy Technicians0
FALSEFALSEFALSEFALSE
Contract placing Phlebotomists0
FALSEFALSEFALSEFALSE
Contract placing Physician Assistants0
FALSEFALSEFALSEFALSE
Contract placing Physical Therapists0
FALSEFALSEFALSEFALSE
Contract placing Physical Therapist Assistants0
FALSEFALSEFALSEFALSE
Contract placing Psychiatric Technicians0
Other Ancillary Labor Category identified in Exhibit 3: Point Value:8162432Value
FALSEFALSEFALSEFALSE
[Type in one Ancillary labor category here]0
ReferenceRelevant Experience - Difficult-to-Fill PositionsEnter an X in the appropriate column associated with contract experienceCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 2> 2, but < 11> 11ValueFile Name (e.g., MY COMPANY.VOLII.ANCILLARY.HARD.TAB2C.pdf) See Table 1, Proposal Organization
Point Value:14284256
FALSEFALSEFALSEFALSE
5.3.3Contract placing Clinical Psychologists0
FALSEFALSEFALSEFALSE0
Contract placing Respiratory Therapists0
ReferenceRelevant Experience - Ancillary Clinical Setting (see note below)Enter an X in the appropriate column associated with clinical settingsCPARS/Signed Document (Attachment 3)
YesNoValueFile Name (e.g., MY COMPANY.VOLII.ANCILLARY.SETTING.TAB2C.pdf) See Table 1, Proposal Organization
FALSEFALSE
1.1Outpatient Clinic (10 point value)0
FALSEFALSE
Community Hospital (10 point value)0
FALSEFALSE
Teaching Hospital (10 point value)0
FALSEFALSE
Other Setting (10 point value)0
ANCILLARY SERVICES MARKET SEGMENT TOTAL0
DENTAL SERVICES MARKET SEGMENT (Relevant experience must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceRelevant Experience - Common Positions (One supporting document must be from the Prime contractor)Enter an X in the appropriate column with the number of FTEs placedCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 3> 3, but < 17> 17ValueFile Name (e.g., MY COMPANY.VOLII.DENTAL.COMMON.TAB2D.pdf) See Table 1, Proposal Organization
Point Value:4080120160
Total PointsFALSEFALSEFALSEFALSE
5.1; 5.2; 5.3Contract placing General Dentists0
FALSEFALSEFALSEFALSE
Contract placing Dental Assistants0
FALSEFALSEFALSEFALSE
Contract placing Dental Hygienists0
FALSEFALSEFALSEFALSE
Contract placing Dental Laboratory Technicians0
ReferenceRelevant Experience - Difficult-to-Fill PositionsEnter an X in the appropriate column associated with contract experienceCPARS/Signed Document (Attachment 3)
FTEs Placed:> 0, but < 1> 1, but < 3> 3, but < 7> 7ValueFile Name (e.g., MY COMPANY.VOLII.DENTAL.HARD.TAB2D.pdf) See Table 1, Proposal Organization
FALSEFALSE
Point Value:4080120160
FALSEFALSEFALSEFALSE
5.3.3Contract placing Specialty Dentists identified in Exhibit 30
DENTAL SERVICES MARKET SEGMENT TOTAL0
MAGNITUDE (Dollar value of clinical services provided) (Supporting document must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceEnter an X in the cell associated with the highest value ID/IQ or requirements contract
Contract Value:> $150K but < $500K> $500K but < $2M> $2M but < $5M> $5MValueCPARS/Signed Document (Attachment 3)
Point Value:150300450600File Name (e.g., MY COMPANY.VOLII.MAGNITUDE.TAB3.pdf) See Table 1, Proposal Organization
FALSEFALSEFALSEFALSE
52.212-2Highest total value (including all options) on a contract of the Prime Contractor0
MAGNITUDE SUBTOTAL0
APPLICABILITY (To whom the clinical services were provided) (Supporting document must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceCustomer (One supporting document must be from the Prime contractor)Enter an X in the appropriate column associated with contract performance with the following customers:
YesNoValueCPARS/Signed Document (Attachment 3)
File Name (e.g., MY COMPANY.VOLII.APPLICABILITY.TAB4.pdf) See Table 1, Proposal Organization
FALSEFALSE
52.212-2Contract with Air Force Medical Services (80 point value)0
FALSEFALSE
Contract with Army Medical Services (80 point value)0
FALSEFALSE
Contract with Defense Health Agency (80 point value)0
FALSEFALSE
Contract with Navy Medical Services (80 point value)0
FALSEFALSE
Contract with Other DoD or Other Federal Agencies (80 point value)0
APPLICABILITY SUBTOTAL0
COMPLEXITY (Where clinical services were provided) (Supporting document must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceGeographical Locations - Highest Demand States (One supporting document must be from the Prime Contractor)Enter an X in the appropriate column associated with contract performance in the following locations:
Yes (70 points)No (No points)ValueCPARS/Signed Document (Attachment 3)
File Name (e.g., MY COMPANY.VOLII.COMPLEXIBILITY.HIGH.TAB5A.pdf) See Table 1, Proposal Organization
FALSEFALSE
1.1Contract with HCW performance in California0
FALSEFALSE
Contract with HCW performance in Florida0
FALSEFALSEMQS Acquisition
Contract with HCW performance in Maryland0
FALSEFALSE
Contract with HCW performance in North Carolina0
FALSEFALSE
Contract with HCW performance in Texas0
FALSEFALSE
Contract with HCW performance in Virginia0
FALSEFALSE
Contract with HCW performance in Washington (State)0
ReferenceGeographical Locations - Difficult-to-Fill LocationsEnter an X in the appropriate column associated with contract experience in the following locations:
Yes (70 points)No (No points)ValueCPARS/Signed Document (Attachment 3)
File Name (e.g., MY COMPANY.VOLII.COMPLEXIBILITY.HARD.TAB5B.pdf) See Table 1, Proposal Organization
FALSEFALSE
5.3.3Contract with HCW performance in Alaska0
FALSEFALSE
Contract with HCW performance in Guam0
FALSEFALSE
Contract with HCW performance in Hawaii0
COMPLEXITY SUBTOTAL0
ORGANIZATIONAL CERTIFICATION
ReferenceOrganizational Health Care Staffing Services Certification (Certification must be from the Prime Contractor)Enter an X in the column if the Prime Contractor has a current health care staffing services certification
Prime (100 points)ValueJoint Commission Certification
File Name (e.g., MY COMPANY.VOLII.CERTIFICATION.TAB6.pdf) See Table 1, Proposal Organization
FALSE
1.3.2Current Joint Commission Health Care Staffing Services Certification0
ORGANIZATIONAL CERTIFICATION SUBTOTAL0
INDEFINITE DELIVERY/INDEFINITE QUANTITY (ID/IQ) CLINICAL SERVICE CONTRACT EXPERIENCE (Supporting document must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceIndefinite Delivery/Indefinite Quantity (ID/IQ) Contract (Supporting document must be from the Prime Contractor)Enter an X in the appropriate column associated with contract experience
Yes (300 points)No (No points)ValueCPARS/Signed Document (Attachment 3)
File Name (e.g., MY COMPANY.VOLII.IDIQ.TAB7.pdf) See Table 1, Proposal Organization
FALSEFALSE
1.5.1Performance on an ID/IQ contract0
ID/IQ CLINICAL SERVICE CONTRACT EXPERIENCE SUBTOTAL0
FIRM FIXED PRICE CLINICAL SERVICE CONTRACT EXPERIENCE (Supporting document must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferenceFirm Fixed Price (FFP) Contract (Supporting documentation must be from the Prime Contractor)Enter an X in the appropriate column associated with contract experience
Yes (200 points)No (No points)ValueCPARS/Signed Document (Attachment 3)
File Name (e.g., MY COMPANY.VOLII.FFP.TAB8.pdf) See Table1, Proposal Organization
FALSEFALSE
52.216-1Performance on a FFP contract0
FFP CLINICAL SERVICE CONTRACT EXPERIENCE SUBTOTAL0
PRIME CONTRACTOR CLINICAL SERVICE CONTRACT EXPERIENCE (Supporting document must be for work that was performed from 1 January 2012 through 30 September 2016)
ReferencePrime Contractor Experience (Supporting documentation must be from the Prime Contractor)Enter an X in the appropriate column associated with contract experience
Yes (500 points)No (No points)ValueCPARS/Signed Document (Attachment 3)
File Name (e.g., MY COMPANY.VOLII.PRIME.TAB9.pdf) See Table 1, Proposal Organization
2.1.6FALSEFALSE
Performance as a Prime Contractor0
PRIME CONTRACTOR CLINICAL SERVICE CONTRACT EXPERIENCE SUBTOTAL0
Note:Relevant Experience - Clinical Settings:
Outpatient Clinic: An outpatient clinic is either part of a hospital designed for the diagnosis or treatment of people with health problems, but do not require to be admitted for overnight care or a standalone ambulatory care facility with no overnight care.
Community Hospital: A community hospital is a short-term general hospital. Can also include a specialty hospital such as those dedicated to obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; and other individually described specialty service.
Teaching Hospital: A teaching hospital is a hospital or medical center that provides clinical education and training to future and current health professionals.
Other Settings: Other settings include non-hospital settings such as academic centers, long-term care facilities, occupational health clinic, prisons, research facilities, and schools.

Market Segment Totals

Market Segment Scores
MQS Acquisition
Offeror Name:0
Technical AreaMarket Segment
PhysicianNursingAncillary ServicesDental Services
Scope0000
Magnitude0000
Applicability0000
Complexity0000
Organizational Certification0000
ID/IQ Contract Experience0000
FFP Contract Experience0000
Prime Contractor Experience0000
SEGMENT TOTAL POINT VALUE0000
0000

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